QA Infection CLI

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Active?: legacy
Program: CC
Requestor: Critical Care QI Team
Collection start: 2009-08-22
Collection end: 2018-12-31
  • Anyone who has this problem and is discharged PRIOR to Jan 1.19, code in TMP
  • Anyone who has this problem and is discharged AFTER Dec 31.18, code using ICD10

The Critical Care QI Team is monitoring Central Line Infections in the ICUs. This project was in collaboration with Critical Care Vital Signs Monitoring.

Data Collection Instructions

For all ICU patients:

If a patient
  • develops a Complication of Central Line Infection while in your unit
  • the CLR-BSI is newly acquired on your unit and not already reported at different unit
  • there is a positive culture (no positive culture, don't code)
  • Project: QAInf
  • Item: Central Line Infection
  • date_var: date (no time) positive blood culture was sent to micro lab.

Don't use TMP as notes

Please do not enter this TMP until you have actually confirmed a DX of CLI exists. Use the Notes field on you laptop as a reminder if needed.

Patient from other ICU with Central Line and possibly CLI

If Patient already has a CLR-BSI present on admission to your unit:

  • in the admitting diagnosis field, enter Central Line Infection.
  • do not enter into Tmp project.
  • if the patient is from another ICU in the city, email the collector at that site to check if CLR_BSI was captured as a complication at that site.


Sampling /Denominator

The denominator used to calculate CLBSI rate are the total patient days with central lines in the Central Line Tracking project before 2013 and the T46 - Central Venous Catheter at 2300 (TISS Item) from 2013 to present.

for which ICU do we report the CLI?

If the QA Infection CLI entry indicates a lab within 48 hours of arriving at a second (or more) ICU, it is reported for the previous ICU. If the sample is more than 48 hours after admission, or within 48 hours of discharge from an ICU to a ward, we report it for that ICU

  • Reported in Director/Manager quarterly reports.
  • separate report to Infection Control (Myrna Dyck), STB and Oaks.
    • August 2018 stopped sending separate report for CLI and VAP for Myra Dyck, infection control.

Cross checks

See QA Infection

Data Integrity Checks (SMW)

Query s tmp apostrophe in commentCCMDB.accdbimplemented
Query s tmp QAInf LT 48 hrs after admitCCMDB.accdbretired
Query s tmp QAInf basicCCMDB.accdbretired
Query s tmp QAInf dx no tmpCCMDB.accdbretired
Query s tmp QAInf tmp no dxCCMDB.accdbretired
Query NDC CLI unacceptable dateCentralized data front end.accdbretired

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